Health Assessment- HESI REVIEW.docx

Health Assessment: HESI Review 1. The nurse is assessing the jugular pulse of a patient. Which jugular pulse component reflects ventricular contraction? a. A wave b. C wave c. V wave d. X wave 2. The nurse is caring for a patient with peripheral vascular disorder. What should the nurse monitor in this patient frequently? Select all that apply. a. Intensity of abdominal pain b. Blood pressure and pulse rate c. Presence of gangrene in the legs d. Thyroid stimulating hormone levels e. Presence of canker sores in mouth 3. Which intervention does the nurse perform while examining the axillae of a patient? a. Assist the patient to a supine position b. Palpate the axillae with both hands c. Raise the patients arm over the head d. Move the arm through the range of motion 4. During the assessment of a pregnant patient the nurse observes that the patient has slumped posture and a flat, expressionless face. On reviewing the medical history, the nurse finds that the patient has missed several regular checkups. Which problem is this patient at highest risk for developing? a. Preeclampsia b. Postpartum depression c. Hyperemesis gravidarum d. Carpal tunnel syndrome 5. The health care provider has instructed the nurse to start ambulation for a bedridden patient. What should be the first step while helping the patient to ambulate? a. Assisting the patient into the sitting position b. Asking the patient to stand up independently c. Checking if the patient needs any assistance while standing up d. Ensuring that the patient is on a sequential compression lower limb device 6. A patient reports, “I have difficulty breathing, and so I can’t sleep at night.” How should the nurse record the patient’s reason for seeking care? a. “Dyspnea and insomnia” b. “The patient has dyspnea and insomnia” c. “Difficulty in breathing and sleepless nights” d. “The patient has difficulty breathing and is sleepless” 7. What is the function of the Cooper’s ligaments in the breast? a. To contain the lobules b. To support the alveoli c. To support the breast tissue d. To form reservoirs to store milk 8. The nurse finds the health care provider is gradually reducing the dose of a patient’s psychotropic medications. Which risk does the nurse hope to minimize with this intervention? a. Falls b. Nausea c. Insomnia d. Dementia 9. The nurse documents the body mass index of a 10-year old child as being in the 75th percentile. What should the nurse interpret from this finding? a. The child is considered obese b. The child is deemed overweight c. The child is labeled underweight d. The child is of a healthy weight 10. A patient experiencing alcohol withdrawal scores a 10 on the Clinical Institute Withdrawal Assessment (CIWA). What would the nurse infer about the patient’s condition from the score? a. Mild withdrawal b. Severe withdrawal c. Moderate withdrawal d. Absence of withdrawal 11. The nurse is assessing a patient with cyanosis who has numbness and bluish discoloration of the skin. Which other signs and symptoms in the patient would support the diagnosis of Raynaud’s phenomenon? Select all that apply. a. Swelling in the arms b. Paleness of the palms c. Burning pain in the arms d. Increased blood pressure e. Increased body temperature 12. The nurse is auscultating the breath sounds of a patient who has undergone abdominal surgery. The patient is not able to tolerate a sitting position in bed. What measure should the nurse take to auscultate the posterior lobe of the lung of the patient? a. Ask another nurse to hold the patient in a sitting position b. Ask another nurse to hold the patient in side-laying position c. Ask another nurse to position the patient in the prone position d. Ask another nurse to raise the patient’s upper back slightly from the bed 13. During an examination the nurse observes a patient’s elongated head, overgrowth of the lower jaw, heavy eyebrow ridge, and coarse facial features. What condition is indicated by this patient’s features? a. Bell’s palsy b. Acromegaly c. Brain attack d. Crushing syndrome 14. The nurse is caring for a patient who reports pain in the right side of the abdomen and right shoulder. The patient report that the pain is most severe after eating a fatty meal. What should the nurse infer from these findings? a. The patient has pancreatitis b. The patient has cholecystitis c. The patient has esophageal spasms d. The patient as gastroesophageal reflux disease 15. What are indicators of health disparities in Hispanics? Select all that apply. a. Cirrhosis death b. Physical assault c. Congenital syphilis d. Fetal alcohol syndrome e. New cases of tuberculosis 16. The nurse suspects geriatric syndrome in an older patient without any medical conditions. What statements by the patient are consistent with this condition? Select all that apply. a. “I’ve lost my appetite” b. “I fell a couple times last month” c. “I feel excessively thirsty a lot of the time” d. “I sometimes have urinary incontinence” e. “I sleep soundly when I go to bed at night” 17. While assessing a child, the nurse suspects that the child has Henoch Schonlein purpura. Which findings in the child are consistent with the nurse’s suspicion? Select all that apply. a. The child has joint pains b. The child has abdominal pain c. The child has maculopapular rashes d. The child has bruising all over the body e. The child’s lesions first appeared in the face 18. The nurse is completing an electronic health record (HER) for a new patient. Which patient data should the nurse include? Select all that apply. a. Scheduled visits b. Clinical findings c. Medical history d. Expenses incurred e. Laboratory results 19. Which medications increase the risk of bleeding in older adult patients? Select all that apply. a. Aspirin (Ecotrin) b. Heparin (Calciparine) c. Iron supplements d. Calcium supplements e. Vitamin C supplements 20. While assessing pain perception in a patient, the nurse finds that the patient has a distorted facial expression toward a pain stimulus. Which cranial nerve damage does the nurse screen for in the patient? a. Cranial nerve IV b. Cranial nerve VI c. Cranial nerve VII d. Cranial nerve IX 21. The nurse is caring for a patient who has bronchoconstriction and impaired skin integrity. The nurse finds that the patient has tachycardia, hypotension, tachypnea, decreased bowel movements, and reduced blood supply to the lower limbs. Which conditions are categorized as highest level priority problems? Select all that apply. a. Obstruction of the airway b. Change in vital signs c. Difficulty breathing d. Reduced circulation e. Risk if infection f. Decreased bowel movements 22. The nurse is caring for a patient with severe anemia. Which actions would the nurse perform during the implementation phase? Select all that apply. a. Recommend that the patient undergo a blood test b. Administer iron supplements to the patient c. Suggest that the patient eat iron-rich food d. Review the patient’s medical reports e. Categorize the patient’s symptoms into clusters 23. While interacting with a pregnant patient, the nurse finds that the patient has cravings for raw eggs, soft cheeses, and unpasteurized dairy foods. Which infections does the nurse anticipate if these foods are consumed? Select all that apply. a. Listeria b. Chlamydia c. Gonorrhea d. Salmonella e. Toxoplasmosis 24. The nurse shines a light straight toward the bridge of the nose of the patient. A bright dot of light appears at the 3 o’clock position in the left eye and the 9 o’clock position in the right eye. What can the nurse interpret from the finding? a. Pseudostrabismus b. Asymmetry in red reflex c. Lack of consensual light reflex d. Asymmetry in corneal light reflex 25. Which findings of a mental status examination of an adolescent patient are considered normal? Select all that apply. a. The patient has darting, watchful eyes b. The patient has a flat, masklike facial expression c. The patient has a moderate pace of conversation d. The patient has tattoos and piercings on the body e. The patient has worn jeans that are torn at the knees 26. What is the term used by the nurse to describe pain in the breast? a. Ectasia b. Mastitis c. Mastalgia d. Gynecomastia 27. Which is indicated in a patient with pathologic S3? a. A stenotic heart valve b. Coronary artery disease c. Vigorous atrial contraction d. Decreased compliance of the ventricles 28. While auscultating the precordium of a patient, the nurse heard the first heart sound (S1). What causes the first heart sound? a. Closing of the mitral valve b. Filling of the ventricle c. Closing of the aortic valve d. Closing of the pulmonic valve 29. While assessing an elderly patient admitted to the hospital for injuries sustained from a fall, the patient says, “I’ve had several injuries from frequent falls in the past.” What conditions might the nurse identify as being responsible for this situation? Select all that apply. a. Syncope b. Dementia c. Spondylosis d. Chronic bronchitis e. Diabetic neuropathy 30. Which emotional characteristics are common in a patient with clinical depression? Select all that apply. a. Irritability b. Aggression c. Rapid mood swings d. Hallucinations e. Extreme sadness 31. The nurse is caring for a patient with a flat nasolabial fold and pain behind the ear. While reviewing the reports, the nurse finds that the patient has Bell’s palsy. Which action by the patient is consistent with the nurse’s assessment? a. The patient may whistle b. The patient may blink the eyes c. The patient may raise both the eyebrows d. The patient may show teeth on the right side 32.